Nokea
The nurse received end of shift report in a high-risk maternity unit. Which patient should the nurse see first?
- A. 26 weeks with placenta previa experiencing blood on toilet tissue after bowel movement (placenta is getting lower)
- B. 30 weeks' gestation with placenta previa whose fetal monitor shows late decelerations
- C. 35 weeks' gestation with grade I abruptio placenta in labor who has strong urge to push
- D. 37 weeks' gestation with pregnancy induced hypertension whose membrane ruptured spontaneously
Correct Answer: C
Rationale: The patient who should be seen first is the 35 weeks' gestation with grade I abruptio placenta in labor who has a strong urge to push. Abruptio placenta is a serious condition where the placenta detaches from the uterine wall before delivery, leading to significant bleeding and potential compromise to both the mother and baby. The strong urge to push indicates that the baby is in distress and immediate intervention is required to prevent potential harm. This patient needs urgent assessment and intervention to ensure the safety of both the mother and the baby.
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A newborn is delivered vaginally in the breech presentation. When examining her baby, the mother asks if the baby has been injured during birth because of the large black and blue areas on the buttocks and legs, The nurse should respond that:
- A. This is not a birth injury probably just a birthmark
- B. These are caused by forceps used to aid in the delivery of the baby
- C. This a temporary complication that will disappear in about a week
- D. These Mongolian spots, common in dark-skinned babies, disappear within a year
Correct Answer: A
Rationale: The large black and blue areas on the buttocks and legs of the newborn are likely Mongolian spots. Mongolian spots are common in infants with dark skin and are not a result of birth trauma. They are benign birthmarks caused by pigment that did not make it to the top layer of the skin before birth. These spots typically fade over time and may disappear completely within a few years. It is important to educate parents about Mongolian spots to alleviate any concerns they may have about their baby's skin markings.
What tion in the FHR that is abrupt and appears to be does the nurse inform this group that they are at in the shape of a W. What is the most likely cause highest risk for? of this?
- A. Sexually transmitted diseases
- B. Compression of the fetal head
- C. Uterine cancer
- D. Compression of the umbilical cord
Correct Answer: D
Rationale: An abnormality in the FHR that is abrupt and appears to be in the shape of a "W" is often indicative of variable decelerations. Variable decelerations typically occur due to compression of the umbilical cord, leading to a temporary decrease in oxygen supply to the fetus. It is important for the nurse to inform this group that they are at the highest risk for compression of the umbilical cord as this can result in fetal distress and potentially lead to serious complications if not promptly addressed.
The nurse is caring for a client in labor with meconium-stained amniotic fluid. What is the priority action?
- A. Administer oxygen to the mother.
- B. Notify the healthcare provider.
- C. Prepare for potential neonatal resuscitation.
- D. Increase IV fluid rate.
Correct Answer: C
Rationale: Meconium-stained amniotic fluid poses a risk of aspiration; preparation for neonatal resuscitation is critical.
During which stage of the menstrual cycle does the endometrium layer thicken?
- A. Proliferative phase
- B. Ovulation phase
- C. Luteal phase
- D. Secretory phase
Correct Answer: D
Rationale: The endometrium layer thickens during the secretory phase of the menstrual cycle. This phase occurs after ovulation and is characterized by the endometrium preparing for possible implantation of a fertilized egg by further thickening and becoming more vascularized. If pregnancy does not occur, the thickened endometrial lining will be shed during menstruation. The secretory phase is under the control of the hormone progesterone, which is produced by the corpus luteum formed in the ovary after ovulation.
A client at 12 weeks' gestation reports mild cramping and spotting. What is the nurse's priority intervention?
- A. Reassure the client that this is normal.
- B. Encourage the client to hydrate.
- C. Advise the client to avoid heavy lifting.
- D. Notify the healthcare provider immediately.
Correct Answer: D
Rationale: Spotting and cramping in early pregnancy could indicate a threatened miscarriage, requiring immediate evaluation.